Emergency Management Unit
1429 Monroe Street
Madison, WI 53711
www.uwpd.wisc.edu
Updated July 20, 2015
Thank you for your interest in the UWPD First Responders. Please read this page before completing the application.
Q: What is the commitment?
A: Three shifts per semester, monthly training, and skills recertification each year. Events are typically four hours long. The monthly meeting is usually the second Monday of every month at 7:00 p.m.
Q: What happens after I submit this application?
A: Your application will be reviewed. If it is acceptable you will be sent information about our interview process. Once you have successfully completed an interview, we will send you a formal acceptance or rejection letter. Those accepted must complete an orientation session before working events.
Q: What is the role of the UWPD First Responders?
A: We operate at a first responder level. Patient transportation services are not provided. We respond to emergency calls on campus, provide medical assessment, and treatment. If ALS care is needed, Madison Fire Department is requested. Available shifts include Friday and Saturday nights, home football games, intramural sports, and other special events on campus.
Q: What are the benefits for joining?
A: On top of meeting new people and getting an opportunity to make a difference through direct patient care, the UWPD First Responders provides: free training including Continuing Medical Education (CME) opportunities and experience working in the EMS field.
Q: Are all members volunteers?
A: Yes, the UWPD First Responders is an all volunteer organization that is operated by student leaders with oversight and financial support from the UW-Madison Police Department.
Q: I'm not a certified EMT but would like to volunteer.
A: Unfortunately we are only accepting applications from certified EMTs or those currently enrolled in an EMT-Basic class.
Q: What happens if I am injured during a shift?
A: As a volunteer you are NOT covered under the Workers Compensation policy of the University. If you are injured, become ill, or are exposed to a hazardous material while on duty medical care costs are your responsibility. You are REQUIRED to have health insurance. Low cost health insurance is available through University Health Services.
Application for the UWPD First Responders
Please fill out this form electronically. If you are unable to do so, please type or print all information neatly.
General Information
Last Name / First Name / Middle Name / Date of Birth / Today’s DateLocal Address / City / State / Zip Code / Cell Phone Number
Permanent Address / City / State / Zip Code / Phone Number
Wisc.edu Email Address / Other Email Address / Current Grade and Anticipated Graduation Date / Major/Area of Study
Driver License Number / State / EMS Certification Level / How did you hear about the First Responders?
Additional Information
Do you have health insurance? (required to provide a copy of your health insurance card) / Y / NHave you ever been convicted of a felony? / Y / N
Have you ever been convicted of DUI/DWI in any State or Province? / Y / N
Has your driver's license ever been suspended or revoked? / Y / N
Has your EMT certification ever been revoked or denied or is it pending such action? / Y / N
Have you ever been excluded from a federally funded healthcare program? / Y / N
If you answered Yes to any of the previous questions, please list explanation in the next section or on a separate sheet of paper.
Record of Law Enforcement Contacts
Date / Municipal/County/State / Law Violated / DispositionCertifications
Copies of certificates or cards must be provided / Expiration Date / Certificate NumberWI EMT-Basic License (Required)
NREMT License (Optional)
AHA CPR Healthcare Provider (Required) / N/A
Other:
EMS Training Facility (required for those currently enrolled in an EMT-Basic course)
Organization / Address / Dates / Instructor & Phone Number-
EMS Related Experience
List paid and volunteer experience, start with current/most recent position
Organization / Address / Dates / Supervisor & Phone Number-
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Work Experience
Start with current/most recent position
Employer / Position Held / Dates / Supervisor & Phone Number-
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References
(Other than relatives or friends) Must list at least two
Name / Email Address / Phone Number / RelationshipEmergency Contacts
Person(s) to contact in case of emergency
Name / Daytime Phone / Evening Phone / RelationshipAgreement
I hereby affirm that I am at least 18 years of age and that the information provided on this form is complete, true and accurate to the best of my knowledge. I also understand that I must currently have and maintain a certification to practice pre-hospital emergency medicine through the UWPD First Responders. I understand that intentional misrepresentation of any information on this form will result in my immediate removal from the UWPD First Responders and may be a violation of law. Further, I agree to abide by the Standing Operating Procedures and BLS Medical Protocols of the UWPD First Responders. I understand that if this application is accepted, I will then be required to attend an orientation class. As part of that class I understand that I will be required to demonstrate my cognitive and practical skills and that my membership will be contingent upon successful demonstration of these skills and completion of all requirements of a probationary member of the UWPD First Responders. I understand that I will be a probationary member for no less than four months following orientation, and that I may terminate or be terminated from affiliation with the UWPD First Responders at any time during the probationary period.
Signature: ______Date: ______
Application Checklist and Attachments
□ Completed application
□ Signed Agreement (Page 4)
□ Attachments (PDFs preferred)
□ Copy of health insurance card (required)
□ Copy of WI EMT-Basic License (required)
□ Copy of NREMT License (optional)
□ Copy of AHA CPR Healthcare Provided card (required)
□ Copy of immunization records (required)
□ Copy of your most recent TB test (required)
Send completed application to:
Email: (preferred)
Fax: 608-890-1737
In Person or Mail:
UW-Madison Police Department
Attn: Bill Curtis
1429 Monroe Street
Madison, WI 53711
Questions or comments?
Bill Curtis, Emergency Management Supervisor
608-212-6966 (mobile)
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